Acute Urinary Retention

Acute urinary retention (AUR) is commonly encountered condition in the emergency department. It is the inability to void voluntarily despite a distended bladder that often leads to agitation or altered mental status in the elderly who are on several medications. Classical patient with AUR is an elderly man with BPH. 


Hypertension or tachycardia may be transient and may resolve after bladder decompression. 



Higher Centres and Receptors involved in Micturation
Micturition involves coordination of high cortical neurologic (sympathetic, parasympathetic, and somatic) and muscular (detrusor and sphincter smooth muscle) functions.






Urinary Retention requires both relaxation of the detrusor muscle (through β-adrenergic stimulation and parasympathetic inhibition) and contraction of the bladder neck and internal sphincter (through α-adrenergic stimulation). In contrast, Urination requires contraction of bladder detrusor muscle (by cholinergic muscarinic receptors) and relaxation of both the internal sphincter of the bladder neck and the urethral sphincter (throughα-adrenergic inhibition). 

Common Causes of Urinary Retention

  • BPH
  • Prostate Cancer, Phimosis, Paraphimosis
  • Meatal Stenosis
  • Prostatitis
  • Medications (Anticholinergics, Antihistaminics, Antipsychotics, BZDs etc.)

Females presenting with AUR should undergo neurologic examination and a pelvic examination to detect possible inflammatory lesions or pelvic masses. 

AUR is a clinical diagnosis but bedside US can be used as an adjunct. Prolonged obstruction may result in impaired renal function and electrolyte imbalance. Thus, renal function studies and Potassium should be checked for those with prolonged retention. Formal abdominal imaging and urodynamic studies can be deferred as an out-patient if the patient appears clinically well. 

A thorough history is required to find the cause/precipitant of Urinary Retention

ED management is limited to bladder decompression with urethral catheterization or suprapubic catheterization (if urethral cath fails). Alpha-blockers can be prescribed during discharge to relax the uretheral muscles. 


Disposition and Indications for admission

Admit in case of:
  • Significant Post Renal Failure
  • Post Obstructive Diuresis
  • Frank Hematuria
  • Clot Retention 
  • Sepsis
Majority of patients with AUR are discharged home after bladder decompression and Urology Clinic review. It is paramount to educate them about catheter care to avoid accidental displacement/removal of the catheter leading to urethral injury. Reg flags include - fever, abdominal pain, catheter blockage, or penile pain. Tho who complain of a sense of urgency despite being on foleys can be treated with oxybutynin, 2.5 milligrams twice/thrice daily. 

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


Nasal Fractures – ED Management

Nasal fracture is a common ED presentation. Very often, its management primarily involves only simple reassurance and arranging timely follow up. 


The nasal pyramid is formed by two rectangular-shaped bones that articulate with the frontal bone, the frontal process of the maxilla, and the perpendicular plate of the ethmoid. A large proportion of the structural integrity is maintained by a cartilaginous framework of the nasal septum, lateral processes, and medial and lateral crura of the alar cartilages.









Examination
Look for bony crepitus, deformity, and edema
Profuse epistaxis suggests nasal fracture. 
Nasal bone mobility is checked by grasping the dorsum of the nose between the thumb and index finger and attempting to rock the nasal pyramid back and forth.
Perform anterior rhinoscopy after applying topical vasoconstrictors and evacuation of clots 

Important examnation findings:

  • Septal Hematoma

Failure to identify and treat a septal hematoma can result in a saddle deformity of the septum, which will require surgical repair. A septal hematoma is a blood-filled cavity between the cartilage and the supporting perichondrium. If left untreated, these pockets of blood easily become infected. The resulting necrosis of the underlying cartilaginous support may result in per- manent saddle nose deformity
  • Mucosal lacerations
  • Head/C Spine trauma
  • Other facial bone injuries
  • Extraocular movements, VA
  • CSF leak
Management
Nasal bone fracture is a clinical diagnosis. Radiologic confirmation of isolated nasal fracture is not required as results of plain films rarely change management. Most nasal fractures do not require immediate intervention and are managed at ENT follow-up within 7-10 days. In ED, ruling out siginificant head trauma is the prioroty in addition to looking for a septal hematoma. Nasal fractures with overlying lacerations are treated as open fractures. Here is a flow chart suggesting ED managemnt of Nasal Bone Fracture:




During ED visits, soft tisssue edema obscures adequate physical examination. Thus, it is recommended to go for an ENT consultation for elective closed reduction in about 7-10 days. Delayed presnetations may develop fibrous connective tissue along the fracture line and lead to worse cosmetic outcome require rhinoseptoplasty. 


References:
  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579544/pdf/523.pdf
  • https://www.aafp.org/afp/2004/1001/p1315.pdf



Take Home:
ED Management of nasal fracture relies on ruling out other potential injuries (Head, C Spine, Face) and looking for local complications such as profuse bleeding and septal hematoma. Most injuries can be managed with reasuurance and pain relief and arranging an ENT follow up in a week. 


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic



Bell’s Palsy

Bell's palsy is an idiopathic LMN palsy involving the facial nerve accounting for up to 3/4 of all cases of unilateral facial paralysis. It is believed that inflammation and swelling of the facial nerve causes compression of the nerve which manifests as facial muscle weakness. However, the exact etiology is controversial. Reactivated herpes simplex virus is thought to be the most probable cause followed by herpes zoster virus.

The facial nerve consists of a:
  • Motor component, which supplies all the muscle of facial expression
  • Sensory branch that carries taste sensation from the anterior two thirds of the tongue through the chorda tympani nerve
  • Parasympathetic fibres reach the lacrimal glands via the greater superficial petrosal nerve, and they reach the sublingual and submaxillary glands via the chorda tympani. 
Bell's palsy is diagnosed upon the abrupt onset of unilateral facial weakness or complete paralysis of all the muscles on one side of the face, dry eye, pain around the ear, an altered sense of taste, hyperacusis, or decreased tearing. On attempted closure, the eye rolls upward (Bell's phenomenon). The disease usually progresses from the onset of symptoms to maximal weakness within three days. 

The most wodely used classification to grade severity of the facial muscle weakness is House-Brackmann classification:



UMN and LMN facial palsy

Classically stroke presents with a UMN type of facial nerve palsy i.e. a supra nuclear lesion sparing of forehead/eyelid muscles (image on right) and lesions beloew the facial nerve nuclei presnet with involvement of upper as well as lower half of face i.e involving forehead/eyelid muscles as well. It is important to look for involvement of limb weakness and deficts in other cranial nerves fucntion as LMN palsy may reperesent a brainstem stroke. 




Diagnosis and Treatment 


Focus on the history and physical examination to identify the possible causes of LMN facial palsy such as:

  • Otitis media
  • Trauma
  • Postsurgical complications
  • Neoplasms
  • Sarcoidosis
  • Lyme Disease 
  • Reactivation of VZV infection


Corticosteroids adminiatered within 3 days of the onset of synmptoms increase the likelihood of recovery and shorten time to recovery as well. Patients with Bell's palsy do not complain of any facial pain and don't have any cranial nerve involvement other than the facial nerve.

Recent literature favors the use of steroids and not antivirals. Sullivan et al in 2007 examined the treatment options for BP in a randomized control trial across 17 sites in Scotland. At three months, 83% of patients in the prednisolone group versus 63.6% of patients in the non-prednisolone group fully recovered. A meta-analysis in 2009 determined there was no significant benefit of combined antiviral and steroid treatment compared to steroids alone. Currently, the recommended treatment regiment for BP is prednisone, 60 to 80 mg per day, for one week or giving 25 mg twice daily for 10 days. 



Eye Care: Prescribe lubricating eye drops for use during the day in addition to a corneal lubricant to use at night. Furthermore, patches or taping the eyelid closed can be used at night. 


Severe disease can result in inability to completely close the eye in addition to decreased lacrimal secretions, leading to drying and tearing of the cornea. 

Summary

  • Bell’s palsy is idiopathic paralysis of the facial nerve and is the most common cause of LMN facial palsy. DO a full neuro exam and look for other cranila nerve involvement to look for potential brainstem CVA.
  • Bell's Palsy is unilateral and acute in onset, progressing over a period of hours and reaching maximal intensity within several days
  • Treatment consists of corticosteroids and eye care. The prognosis of BP is excellent, with 85% of patients regaining function within three weeks

References:
  1. Fahimi J, Navi BB, Kamel H. Potential misdiagnoses of Bell's palsy in the emergency department. Annals of emergency medicine. 2014 Apr 1;63(4):428-34.
  2. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, Davenport RJ, Vale LD, Clarkson JE, Hammersley V, Hayavi S, McAteer A, Stewart K, Daly F. Early treatment with prednisolone or acyclovir in Bell’s palsy. N Engl J Med. 2007 Oct 18;357(16):1598-607.
  3. https://cks.nice.org.uk/bells-palsy#!scenario
  4. Quant EC, et al. The benefits of steroids versus steroids plus antivirals for treatment of Bell’s palsy: a meta-analysis. BMJ. 2009;339:b3354 
Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic